Table 5 - uploaded by Arthur J Hartz
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Much of the research comparing specialists and generalists is from studies of patients who had a myocardial infarction. The present study systematically examined this research.
Medline was used to search for all articles published from 1990 to 2003 that compared cardiologists and generalists for adjusted mortality rates of patients with myocardial...
Contexts in source publication
Context 1
... the studies by Ayanian et al 6,24 assessed whether cardiologists and generalists collaborated in the care of patients with myocardial infarction. Unadjusted and adjusted mortality comparisons of generalists and specialists are shown in Table 5. Mortality was assessed at 30 days and 1 year for 5 of the studies and in-hospital for 4 others. ...
Context 2
... Table 5 we did not include a study of patients who survived a myocardial infarction for at least 3 months. 24 In that study the mortality rate in the postmyocardial infarction period for patients man- aged by generalists alone was 19.1% compared with 11.8% for patients managed by cardiologists alone or with a generalist, OR 1.75, P .001. ...
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... At one end there is the model that is widely considered to be the gold-standard model, whereby AMUs are closed, with all patients being cared for by a single physician working in a generalist capacity. 180 At the other end are open units, with 'take triage' specialist models, which are premised on studies showing that earlier specialist input improves outcomes for patients with specific conditions, such as myocardial infarction 181 and COPD, 182 and further driven by concerns that specialists working intermittently on AMUs have difficulty in maintaining the skills required for the safe management of the medical take. 183,184 We found that there were no significant differences between outcomes for the generalist and take triage models of care with regard to LOS (3.2 days vs. 3.5 days, respectively) or for the probability of mortality or re-admission. ...
Background
The increasing number of older, complex patients who require emergency admission to hospital has prompted calls for better models of medical generalist care, especially for smaller hospitals, whose size constrains resources and staffing.
Objective
To investigate the strengths and weaknesses of the current models of medical generalism used in smaller hospitals from patient, professional and service perspectives.
Methods
The design was a mixed-methods study. Phase 1 was a scoping and mapping exercise to create a typology of models of care, which was then explored further through 11 case studies. Phase 2 created a classification using the Hospital Episode Statistics of acute medical ‘generalist’ and ‘specialist’ work and described differences in workload and explored the links between case mix, typology and length of stay and between case mix and skill mix. Phase 3 analysed the relationships between models of care and patient-level costs. Phase 4 examined the strengths and weaknesses of the models of care through focus groups, a discrete choice experiment and an exploration of the impact of typology on other outcomes.
Results
In total, 50 models of care were explored through 48 interviews. A typology was constructed around generalist versus specialist patterns of consultant working. Twenty-five models were deployed by 48 hospitals, and no more than four hospitals used any one model of care. From the patient perspective, analysis of Hospital Episode Statistics data of 1.9 million care episodes found that the differences in case mix between hospitals were relatively small, with 65–70% of episodes accounted for by 20 case types. The skill mix of hospital staff varied widely; there were no relationships with case mix. Patients exhibited a preference for specialist care in the discrete choice experiment but indicated in focus groups that overall hospital quality was more important. From a service perspective, qualitative work found that models of care were contingent on complex constellations of factors, including staffing, the local hospital environment and policy imperatives. Neither the model of care nor the case mix accounted for variability in the length of stay (no associations were significant at p < 0.05). No significant differences were found in the costs of the models. Professionally, the preferences of doctors for specialist versus generalist work depended on their experiences of providing care and were associated with a healthy organisational culture and a co-operative approach to managing emergency work. Concepts of medical generalism were found to be complex and difficult to define, with theoretical models differing markedly from models in action.
Limitations
Smaller hospitals in multisite trusts were excluded, potentially leading to sample bias. The rapidly changing nature of the models limited the analysis of typology against outcomes.
Conclusions
The case mix of smaller hospitals was dominated by patients with presentations amenable to generalist approaches to care; however, there was no evidence to support any particular pattern of consultant working. Matching hospital staff to better meet local need and the creation of more collaborative working environments appear more likely to improve care in smaller hospitals than changing models.
Future work
The exploration of the relationships between workforce, measures of hospital culture, models of care, costs and outcomes in both smaller and larger hospitals is urgently required to underpin service reforms.
Study registration
This study is registered as Integrated Research Application System project ID 191393.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research ; Vol. 9, No. 4. See the NIHR Journals Library website for further project information.
... For example, in comparisons between generalist-led hospitalized care for MI and HF, several studies have demonstrated that cardiology-led care has been associated with lower rates of mortality. [3][4][5] Although data on the types of cardiac technology and use of cardiac procedures were described previously, we have not found detailed information on the types of inpatient cardiology services provided at VA medical centers nationwide. 1,6,7 To develop further improvements in delivery of cardiovascular care within the VA, a better understanding of the types of resources that are currently available within the VA system must be made available. ...
A survey found that of cardiology services were widely available at facilities across the US Department of Veterans Affairs, but the types of services varied considerably based on facility complexity.
... Studies have shown that the treating physicians' specialty in-hospital might play an important role for the prognosis of a patient. Patients who were treated by cardiologists had lower mortality rates in comparison to patients who were treated by other internists or general practitioners (GP) [20][21][22][23][24]. ...
... The results of our large study, including almost 160,000 patients with MI, suggest a lower mortality risk in patients who received ambulatory cardiology care within the first year after MI diagnosis in comparison to patients who did not receive ambulatory cardiology care. These findings are in line with results from studies in other countries and studies examining the impact of physician specialty in hospital-care settings [20][21][22][23][24][25]. ...
... Only half of the patients in our sample consulted a cardiologist during the first year. The reasons why patients did not see a cardiologist might be diverse and could include individual patient characteristics [24], a possible cardiologist follow-up-treatment in-hospital (which we were not able to assess with our data), an ongoing rehabilitation, trust in the GP or difficulties in the access to specialists. In a German survey, N30% of the interviewed persons in rural districts stated that they were discontented with the access to specialists [38]. ...
Background:
With a mortality rate above European average, myocardial infarction (MI) is the second most common cause of death in Germany. Data about post-MI ambulatory care and mortality is scarce. We examined the association between ambulatory treating physicians' specialty and the mortality of post-MI patients.
Methods:
Medical claims data of all 17 German regional Associations of Statutory Health Insurance physicians were analyzed, which cover approximately 90% of the German population. Patients with a new diagnosis of a MI in 2011 were divided into treatment groups with and without ambulant cardiology care within the first year after MI diagnosis. Propensity-score matching based on socio-demographic and clinical variables was performed to achieve comparability between groups. The 18-month mortality rate was derived employing a validated method.
Results:
158,494 patients with a new diagnosis of MI had received post-MI ambulatory care in 2011. Half of them (51%) had at least one ambulatory contact with a cardiologist within the first year. During a follow-up of 18months, the mortality rate before and after propensity-score matching was 19% and 14% in patients without cardiology care and 6%, respectively, in patients with cardiology care (χ(2)=666.7; P<0.000 after propensity adjustment). Patients who only saw a cardiologist and had no additional contact to an ambulant general practitioner (GP)/internist within the first year did not have increased survival rates.
Conclusions:
Outpatient follow-up care by a cardiologist in combination with consultations of GP/internists within the first year may be of importance for the prognosis of MI patients.
... Primary care providers typically carry the main clinical responsibility for multimorbid patients, except when uncommon conditions are involved [7]. Patients with a relatively low socio-economic status and a correspondingly high disease burden have been shown to use a comparable amount of primary care services, but less specialized out-patient care, compared to patients from higher socioeconomic strata [14,15]. ...
Rationale and aims: Accumulating evidence shows that diseases tend to cluster in diseased individuals, so-called multimorbidity. The aim of this study was to analyze multimorbidity patterns, empirically and theoretically, to better understand the phenomenon. Population and methods: The Norwegian population-based Nord-Trøndelag Health Study HUNT 3 (2006-8), with 47,959 individuals aged 20-79 years. A total of 21 relevant, longstanding diseases/malfunctions were eligible for counting in each participant. Multimorbidity was defined as two or more chronic conditions.Results: Multimorbidity was found in 18% of individuals aged 20 years. The prevalence increased with age in both sexes. The overall age-standardized prevalence was 42% (39% for men, 46% for women). ‘Musculoskeletal disorders’ was the disease-group most frequently associated with multimorbidity. Three conditions, strategically selected to represent different diagnostic domains according to biomedical tradition; gastro-esophageal reflux, thyroid disease and dental problems, were all associated with both mental and somatic comorbid conditions. Conclusions and implications: Multimorbidity appears to be prevalent in both genders and across age-groups, even in the affluent and relatively equitable Norwegian society. The disease clusters typically transcend biomedicine’s traditional demarcations between mental and somatic diseases and between diagnostic categories within each of these domains. A new theoretical approach to disease development and recovery is warranted, in order to adequately tackle ‘the challenge of multimorbidity’, both empirically and clinically. We think the concept allostatic load can be systematically developed to “capture” the interrelatedness of biography and biology and to address the fundamental significance of “that, which gains” versus “that, which drains” any given human being.
... Primary care providers typically carry the main clinical responsibility for multimorbid patients, except when uncommon conditions are involved [7]. Patients with a relatively low socio-economic status and a correspondingly high disease burden have been shown to use a comparable amount of primary care services, but less specialized out-patient care, compared to patients from higher socioeconomic strata [14,15]. ...
... 9 She even found that average technical quality of care from generalists was better than from specialists, 10 even for a major illness. 11 But recruitment to primary care continues to fall, although specialists concentrate in affluent cities and desert entire states where patients are unprofitable. ...
Sir James Mackenzie is generally accepted as the founder of research by general practitioners in Great Britain, studying
their own patients where and how they actually live. His pioneering work on arrhythmias was a foundation for modern cardiology,
consolidated by his pupil Thomas Lewis, Britain’s first full-time clinical researcher for the Medical Research Council. Mackenzie
became a dominant figure in public imagination, more widely celebrated than any later generalist. At the clinical research
institute he founded at St Andrews in 1919, he hoped to set in train a permanent and growing body of longitudinal clinical
research outside hospitals, by community generalists studying their own patients. This article tries to explain the failure
of this project: how it influenced later research by general practitioners and others in primary care after creation of the
National Health Service (NHS) in 1948 and its relevance today to primary care research policy. Such research is now becoming
an urgent necessity, for the British National Health Service to survive as a public service and as a foundation for democratic
development of biosciences.
... The benefit especially accrues from savings among people with high burdens of morbidity as measured by the ACG System. In the US (where most people can go directly to specialists), individual specialists see patients with less severe individual diseases than do generalists, when viewed from the vantage of disease-oriented specialty practice [28], but specialists as a group dominate the care of people with high burdens of morbidity, because people with high burdens of morbidity often see multiple specialists. Thus, a disease-bydisease approach to understanding use of services provides a distorted view of the health needs of the population and the challenges to coordinate care through primary care practice. ...
Multimorbidity is increasing in frequency. It can be quantitatively measured and is a major correlate of high use of health services resources of all types, especially over time. The ACG System for characterizing multimorbidity is the only widely used method that is based on combinations of different TYPES of diagnoses over time, rather than the presence or absence of particular conditions or numbers of conditions. It incorporates administrative data (as from claims forms or medical records) on all types of encounters and is not limited to diagnoses captured during hospitalizations or other places of encounter. It can be employed in any one or combination of analytic models, and can incorporate medication use if desired. It is being used in clinical care, management of health services resources, in health services research to control for degree of morbidity, and in understanding morbidity patterns over time. In addition to its research uses, it is being employed in many countries in various applications as a policy to better understand health needs of populations and tailor health services resources to health needs.
... Certaines études ont rapporté une différence significative concernant la mortalité et la morbidité de patients selon qu'ils sont suivis par un spécialiste ou par un omnipraticien [7,8]. De plus, ces études suggèrent que le suivi par un médecin spécialiste améliore la qualité des soins de patients ayant subi un IAM [8,9]. Le nombre de visites médicales et le lieu de consultation peuvent aussi avoir une influence sur les soins dans le cas de l'IAM. ...
... En effet, on observe des taux de mortalité plus bas chez les patients qui ont été revascularisés [14][15][16][17]. Bien que certaines études démontrent l'influence de facteurs, tels que le type de professionnel consulté, le lieu de consultation ou le nombre de visites médicales dans les soins ambulatoires de l'IAM [6,8,9]. Aucune étude publiée décrit les liens entre ces facteurs ou avec d'autres variables importantes comme l'âge, le sexe, et la présence de procédure de revascularisation dans le contexte du système de santé québécois. ...
... Le nombre de visites médicales ambulatoires des patients pourrait être erroné, car les individus peuvent être suivis en clinique privée, hors d'entente de la RAMQ, dans un établissement hors de la province ou encore dans un centre local de services communautaires (CLSC). Les fichiers médico-administratifs permettent, en premier lieu, de documenter la réalité des maladies chroniques en évaluant l'ampleur du problème et en identifiant les caractéristiques de la population atteinte (carac- 208 (3,6) 166 (2,9) 488 ( ...
Description of ambulatory care of AMI, in Quebec population.
A retrospective cohort study was designed to classify and propose a typology of ambulatory care.
The studied population was included in all 25 years and older inpatients residing in Quebec, whose admission were from January to December 2000. The principal variables were: the number of medical visits, the type of consulted physicians and the place of consultation. The secondary variables were: age, sex and the presence of a revascularization.
A typology of ambulatory care was created from principal variables. Men, younger patients and receiving a revascularization in the index hospitalization were cared for by a specialist.
... Among high-cost beneficiaries, the 27.8 percent attributed to a medical specialist as their USOC physician had U.S.$1,839 greater costs than those attributed to primary care physicians, representing roughly 4 percent of the mean cost of care. Although this may reflect unmeasured patient preferences and health status differences, research provides mixed results whether management by specialists leads to better outcomes or lower costs (Donohoe 1998;Hartz and James 2006;Smetana et al. 2007). Moreover, medical specialists functioning as USOC physicians may provide inadequate primary care outside the scope of their specialty. ...
To identify factors associated with the cost of treating high-cost Medicare beneficiaries.
A national sample of 1.6 million elderly, Medicare beneficiaries linked to 2004-2005 Community Tracking Study Physician Survey respondents and local market data from secondary sources.
Using 12 months of claims data from 2005 to 2006, the sample was divided into predicted high-cost (top quartile) and lower cost beneficiaries using a risk-adjustment model. For each group, total annual standardized costs of care were regressed on beneficiary, usual source of care physician, practice, and market characteristics.
Among high-cost beneficiaries, health was the predominant predictor of costs, with most physician and practice and many market factors (including provider supply) insignificant or weakly related to cost. Beneficiaries whose usual physician was a medical specialist or reported inadequate office visit time, medical specialist supply, provider for-profit status, care fragmentation, and Medicare fees were associated with higher costs.
Health reform policies currently envisioned to improve care and lower costs may have small effects on high-cost patients who consume most resources. Instead, developing interventions tailored to improve care and lowering cost for specific types of complex and costly patients may hold greater potential for "bending the cost curve."
... McAlister and colleagues report specialty care improved disease-specific measures, such as appropriate prescription drug use and insulin use [33]. The findings about the relative effectiveness of specialty care for patients with cardiovascular disease are mixed32333435363738. Studies using Medicare claims data identified a mortality differential after acute myocardial infarctions based on physician specialty [34,35]. ...
Despite efforts to eliminate health disparities, racial, ethnic, and geographic groups continue lag behind their counterparts in health outcomes in the United States. The purpose of this study is to determine variation in specialty care utilization by chronic disease status. Data were extracted from the Commonwealth Fund 2006 Health Care Quality Survey (n = 2475). A stratified minority sample design was employed to ensure a representative sample. Logistic regression was used in analyses to predict specialty care utilization in the sample. Poor perceived health, minority status, and lack of insurance was associated with reduced specialty care use and chronic disease diagnosis.
